Snodgrass Urethroplasty Research Articles

Effect of complications of Snodgrass surgery and Duckett surgery for hypospadias

Objective To investigate urethral plate tubularized incised angioplasty (Snodgrass) and pedicle island skin flap angioplasty (Duckett) operation on hypospadias complications. Methods In our hospital, 241 patients with hypospadias were selected from January 2005 to January 2016 were selected. According to the different treatment methods these patients were divided into Snodgrass group(n=123) and Duckett group(n=118). Operation time, intraoperative blood loss, hospital stay, the clinical effect and complications of the two groups were observed. Results The total efficiency (99.1%) of Snodgrass group was significantly higher than that of Duckett group (80.0%, P<0.05). The operative time, blood loss, length of stay hospital of Snodgrass group was significantly less than Duckett group(P<0.01); The incidence of complications (13.8%) of Snodgrass group was significantly lower than that of Duckett group (31.3%, P<0.01). Conclusions Compared with the Duckett operation, Snodgrass urethroplasty for patients with hypospadias can effectively improve the patient's symptoms, reduce the occurrence of complications quickly and effectively. Key words: Hypospadias; Postoperative Complications

Outcome of Snodgrass urethroplasty by modifying tubularization and dartos layer in Erbil

Background and objective: Snodgrass first described the tubularized, incised plate (TIP) urethroplasty for distal hypospadias repair in 1994. This study aimed to find out whether there is any difference in the fistula rate with single versus double layer tubularization, and the use of ventral versus dorsal dartos layer. Methods: Between May 2009 and July 2014, tubularized incised plate urethroplasty was performed for correction of hypospadias in Erbil for 112 patients with age ranging from 1-32 years. Five patients were excluded from the study because of lack of adequate follow up. Data were analyzed using the statistical package for the social sciences. Results: Urethral fistula occurred in seven cases (6.5%).The use of an additional reinforcing second layer for the tubularization had a significant effect on decreasing the fistula formation (P = 0.05). The fistula rate was slightly lower with dorsal dartos flap (5.4%) than ventral dartos flap (7.8%). Conclusion: The urethral plate, when dissected, should be thick enough to allow for tubularizationin two layers. Both dorsal and ventral dartos flaps are effective in preventing urethral fistula.

Grafted tubularised incised-plate urethroplasty: An objective assessment of outcome with lessons learnt from surgical experience with 263 cases

ObjectiveSnodgrass urethroplasty remains the preferred technique in primary distal hypospadias but development of meatal stenosis often limits distal extension of the midline incision of the urethral plate (MIUP), which remains a limiting factor in reconstructing an apical neomeatus (NM). We here-in assess the cosmetic and functional outcome with distal extension of the MIUP in grafted tubularised incised-plate urethroplasty (G-TIP) repair. Patients and methodsThis prospective study included the surgical experience of 263 cases of primary hypospadias operated upon between 2012 and 2015. The G-TIP technique included standard steps of Snodgrass urethroplasty, including degloving and harvesting of glans wings, followed by MIUP that was extended distally beyond the margins of the urethral plate (UP) into the glans. The incised bed was grafted with a free preputial skin graft and fixed to the bed with polydioxanone 7-0 suture. The UP was tubularised and the suture line reinforced with a Dartos flap. The urethral catheter was removed at 7–10days after the repair and the outcome was assessed at follow-up using the Hypospadias Objective Scoring Evaluation (HOSE) system. ResultsAn apical NM was achieved in 96% of the patients with a 3.7% incidence of urethrocutaneous fistula. The presence of suture tracks and graft at the margins of the NM were seen in the initial 4% and 5% of cases, respectively. Acceptable cosmetic results, with objective HOSE scores of >14, were achieved in 96% of cases. ConclusionThe G-TIP repair is a straightforward and feasible technique facilitating reconstruction of an apical NM, with an optimum outcome based on HOSE scoring. However, multicentre data are needed for undertaking comparative analysis and to assess the universal applicability of this technique in primary hypospadias.

100 Can the Snodgrass urethroplasty be a universal technique for all types of hypospadias?

100 Can the Snodgrass urethroplasty be a universal technique for all types of hypospadias?

Comparative study of Mirs(') (Mushtaq and Shabir) technique of prepuce preserving minimally invasive urethroplasty with Snodgrass urethroplasty for repair of distal hypospadias without chordee…A prospective study.

Background:There is no single, universally applicable technique for hypospadias repair and numerous techniques have been practised from time to time. We compare the results of our new technique (Mirs’ technique also called Mush & Shab's technique) to Snodgross urethroplasty. Mirs’ technique is a modified version of Thiersch-Duplay urethroplasty.Material and Methods:This prospective comparative study was carried out in a tertiary care hospital of Northern India over a period of 3 years from March 2010 to March 2013 and included 120 patients of anterior (distal penile, subcoronal, coronal and glanular) hypospadias without chordee. They underwent either Mirs’ technique (group 1 n = 60) or Snodgrass technique (group 2 n = 60). Follow-up was at 1-week, 1-month, 3 months and 6 months.Results:The mean operative time was 55 min (range: 43-70 min) in group 1 and 71.9 min (range: 60-81 min) in group 2 (P < 0.001). Urethrocutaneous fistula developed in two and four patients in group 1 and 2, respectively. Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success rate between the two groups. Three cases of glanular dehiscence were detected (one in group 1 and two in group 2); the patient from group 1 had a successful repair using the already preserved prepuce.Conclusion:Mirs’ modification of Thiersch-Duplay technique for distal hypospadias is a time saving procedure with a lower overall complication rate. Valuable local tissue is preserved to deal with any complication that may occur. Analgesic requirement was significantly lower in this minimally traumatic technique. As it is less time consuming, simple and easy to learn with a short learning curve, this technique deserves application in cases of distal hypospadias.

Snodgrass urethroplasty for hypospadias repair: A retrospective comparison of two variations of the technique

The Snodgrass technique is a widely accepted method for hypospadias repair. In this paper, we compare two methods of performing this technique with respect to postoperative complications and outcome, with emphasis on meatal stenosis, fistula formation, residual chordee and penile torsion. We reviewed the results of 320 cases treated by Snodgrass urethroplasty between March 2007 and February 2012 at the maternity and children’s hospital of Almadinah Almunawwarah, Kingdom of Saudi Arabia. The two methods differed in the extent of urethral plate incision, the type of flap used and the degree of degloving of the penile skin. In group A (115 boys), the urethral incisions and the sagittal deep longitudinal incision were extended from the posterior edge of the hypospadiac meatus to the tip of glans, and the neourethra was covered by a dorsal preputual flap. In group B (205 boys), the urethral incisions and the deep longitudinal incision extended to the mid-glans, and the neourethra was covered by a lateral dartos flap. After tubularization of the urethral plate and a circumferential incision proximal to the coronal sulcus from each edge of the urethral plate, the penile skin was degloved from 1 cm proximal to the hypospadiac meatus in group A and to the penoscrotal junction in group B. The mean age of the children was 1.5 years. Complications occurred in 45 patients (14.1%). A urethrocutaneous fistula occurred in 8 patients (2.5%), with 6 in group A (5.2%) and 2 in group B (0.98%). Ten patients (3.1%) developed meatal stenosis, with 7 in group A and 3 in group B. Penile torsion was recorded postoperatively in 13 patients (total rate, 4.1%), with 9 cases in group A (7.8%) and 4 in group B (2.0%). The differences between the two groups were statistically significant. A shorter urethral plate incision, use of a lateral dartos flap to cover the neourethra and more extensive skin degloving in Snodgrass urethroplasty reduce the rate of complications.

To Evaluate the Role of Vascularised Dorsal Dartos Flap in Snodgras Urethroplasty

Background: Hypospadias is a common congenital anomaly of male urethra. Surgical repair is the only treatment of this defect, but there is no single, universally acceptable technique for its repair . Snodgrass technique is now popular for its low complication rate, shorter operative time, vertically oriented slit like meatus and better cosmetic outcome. Objective: To evaluate the role of vascularized dorsal dartos pedicle flap over the neourethra in terms of postoperative urethrocutaneous fistula formation between two groups of patients of distal penile hypospadias. Methodology: Thirty two patients were included in this study. They were divided in group A and group B on the basis of serial number of patients. Snodgrass urethroplasty was done in group A considered as control and in group B, Snodgrass urethroplasty was done with additional dorsal dartos flap by buttonhole technique considered as interventional group. The outcome of both groups in terms of post operative urethrocutaneous fistula were evaluated. Results: In this study in group A, urethrocutaneous fistula developed in 6 patients out of 16 patients. Among the fistulas, 5 were situated at the coronal level and 1 at the hypospadiac meatus level. In group B, urethrocutaneous fistula developed in 1 patient out of 16 patients and the fistula occurred at the coronal level. In either group, all the fistulas are developed after removal of the catheter. In terms of post operative urethrocutaneous fistula formation in between the two groups, the results were statistically significant. Conclusion: Snodgrass urethroplasty with additional dorsal dartos flap by buttonhole technique have better outcome than without additional dorsal dartos flap in terms of postoperative fistula formation. DOI: http://dx.doi.org/10.3329/jpsb.v2i1.15161 Journal of Paediatric Surgeons of Bangladesh (2011) Vol. 2 (1): 31-35

Role of double breast vascularized preputial Dartos flap reinforcement in Snodgrass Urethroplasty

DOI: http://dx.doi.org/10.3329/jafmc.v8i1.13539 JAFMC Vol.8(1) 2012 pp.43-45

Modified tubularized incised plate urethroplasty

Aim:To share our experience of doing tubularized incised plate urethroplasty with modifications.Materials and Methods:This is a single surgeon personal series from 2004 to 2009. One hundred patients of distal hypospadias were subjected for Snodgrass urethroplasty with preputioplasty. The age range was 1 to 5 year with mean age of 2.7 years. Selection criteria were good urethral plate, without chordee and torsion needing complete degloving. Main technical modification from original Snodgrass procedure was spongioplasty, preputioplasty, and dorsal slit when inability to retract prepuce during surgery.Results:Average follow-up period is 23 months. Seven (7%) patients developed fistula and one patient had complete preputial dehiscence. Phimosis developed in three (3%) patients and required circumcision. Dorsal slit was required in seven patients. One patient developed meatal stenosis in postoperative period. All other patients are passing single urinary stream and have cosmesis that is acceptable.Conclusions:Modified tubularized incised plate urethroplasty with preputioplasty effectively gives cosmetically normal looking penis with low complications.

Functional Evaluation of Mid and Distal Penile Hypospadias Surgery with Special Reference to Uroflowmetry

Background: To assess two different operative techniques in hypospadias with special emphasis on urinary flow with the help of uroflowmetry. Material and Methods: In this prospective study, all patients underwent either Snodgrass or Mathieu urethroplasty. Preoperative uroflowmetry was done in every patient. Postoperative uroflowmetry was done 2 weeks after stitch removal only in those patients who were not having urethral fistula. Postoperative dilation was done only in those patients who had decreased urinary flow as compared to preoperative values. Results: Fifty patients were included in this 2-year study. Uroflowmetry was performed in 37 patients. Twenty-two patients underwent Snodgrass urethroplasty and the other 15 had Mathieu urethroplasty. Pre- and postoperative Q_max values were 6.57 ± 2.67 and 7.36 ± 3.90 ml/s, respectively. Q_avg values were 4.16 ± 1.87 and 4.52 ± 2.50 ml/s, respectively. Although statistically insignificant, the Snodgrass technique appeared to be relatively better than Mathieu’s technique. Conclusion: Uroflowmetry can predict the need for dilation in hypospadias. The Snodgrass technique appears to be functionally better than Mathieu’s technique. With avoidance of unnecessary trauma due to dilation, the cooperation of pediatric patients can be achieved.

Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: A prospective randomized study

To evaluate the outcomes of combined Mathieu and Snodgrass urethroplasty for distal hypospadias repair and to compare them with the two techniques separately. Between January 2006 and February 2009, patients with distal hypospadias were prospectively randomized to undergo one of the three following urethroplasty techniques: Mathieu urethroplasty, Snodgrass urethroplasty or a combination of the two. Operative time, intraoperative, early and late postoperative complications were reported for each procedure. 101 patients were included in this study. The Mathieu technique was used for 30 patients, Snodgrass repair was carried out in 37 patients and 34 patients underwent the combined technique. Operative time ranged from 43 to 120 min. Eight patients developed urethrocutaneous fistulae. Meatal stenosis was encountered in five cases. Thirty-seven patients had rounded meatus, while a slit-like urethral opening was found in 64 cases. In our hands, the combined Mathieu and Snodgrass urethroplasty technique provided a better cosmetic outcome than the Mathieu technique with no incidence of meatal stenosis as seen with the Snodgrass technique.

Snodgrass Urethroplasty: Grafting the Incised Plate—10 Years Later

We report our retrospective, nonrandomized, single center experience with modified tubularized incised urethral plate repair, consisting of grafting the incised urethral plate before tubularization, as first introduced 10 years ago. Indications, technical points and results are described. From 1997 to 2007 at our unit 1,095 cases of hypospadias were treated, including 75% primary and 25% repeat cases. Of primary cases 18 (8%) of those suitable for tubularized incised urethral plate were instead selected for a grafted tubularized incised urethral plate. All 18 patients were characterized anatomically by a small glans, a flat urethral groove and a long spongiosum defect. Of repeat cases 83 were suitable for a tubularized incised urethral plate, of which 44 (53%) were selected for the modified procedure. Grafted tubularized incised urethral plate surgery consisted of an extended longitudinal incision of the urethral plate distal beyond the neomeatal line associated with scar excision in repeat cases. The resulting urethral plate defect was then lined with a graft. Mean followup was 36 months (range 4 to 122). Complications were noted in 8 repeat cases (13% overall), representing 18% of this subgroup. Case selection is a crucial factor that influences the quality of tubularized incised urethral plate results. However, in most repeat cases scarring may lead to an increased complication rate after tubularized incised urethral plate surgery. The grafted modification has the advantage of extending indications for the tubularized incised urethral plate to cases in which another surgical procedure would be necessary. To our knowledge we present the first series of primary and repeat cases.

Repair of hypospadias with severe chordee using a long, wide, U-shaped flap that preserves ventral penile tissues intact for second-stage urethroplasty

Purpose The aim of the study was to report a new technique for repairing hypospadias with severe chordee (HSC). Methods Our new technique involves making a long, wide, U-shaped incision on the ventral penis from the coronal sulcus to very distal to the meatus and dissecting to create a flap (U-flap). During dissection, the urethra is divided just proximal to the meatus. After release of chordee, the U-flap is returned to the ventral penile shaft and sutured in place. A buttonhole made distally in the U-flap is anastomosed to the cut end of the urethra to create a neomeatus. Snodgrass urethroplasty is performed 6 to 18 months later. We have treated 11 patients with HSC (mean age, 22.3 months) using this technique. Results Postoperatively, all U-flaps were viable. The neomeatus appeared to be more proximal because the penis was straighter. Urethroplasty using the central part of the U-flap was uncomplicated by scar tissue and successful in all cases. After a mean follow-up of 15.7 months, all patients have satisfactory penises without stenosis or diverticulum, although 1 had fistula. Conclusion Our U-flap technique allows the ventral penis to be preserved intact without scarring for second-stage urethroplasty and as a result is well suited for treating HSC.

Combined Use of Mathieu Procedure with Plate Incision for Hypospadias Repair: A Randomized Clinical Trial

To introduce a simple and effective technique for urethroplasty of distal hypospadias, using the advantages of both standard techniques of Snodgrass and Mathieu to reduce or eliminate the shortcomings of each. Forty patients with primary distal hypospadias were randomized between two groups (20 in each). Patients in group I underwent standard Snodgrass urethroplasty, whereas those in group II were operated with our novel technique, Mathieu-Incised Plate (Mathieu-IP), comprising preparation of a parameatal-based skin flap as in the Mathieu procedure together with modifications (adopted from Snodgrass urethroplasty) such as a complete longitudinal incision on the urethral plate as well as coverage of the neourethra with an inner preputial flap. Operative data and outcomes of both procedures were analyzed prospectively after 1 year of follow-up. Both groups were age matched (group I: 7.05 +/- 4.85 years; group II: 7.31 +/- 2.17 years), and there were no significant differences in mean operative time (95 minutes versus 100 min in groups I and II, respectively). There were significant differences between the two groups in terms of complications. Whereas 3 cases of posturethroplasty meatal stenosis and 2 of urethrocutaneous fistula (5 complications, 25%) were detected in the Snodgrass group, neither of these complications occurred in the Mathieu-IP group. All 40 patients benefited from a slit-like meatus. Combining the Mathieu procedure with plate incision could be considered a promising simple technique to achieve a normally shaped meatus and to reduce the rate of meatal-related complications, the major concern with the Snodgrass procedure.

Tubularized incised plate urethroplasty with de-epithelialized flap

To improve the results of tubularized plate urethroplasty by adding de-epithelized flap. Twenty-five cases of hypospadias who underwent Snodgrass urethroplasty using de-epithelialized flap were studied. The minimum period of follow-up in this series was 1 year. The resultant neo-meatus was vertically oriented and slit like. Glans was conical which is cosmetically well accepted. Penile raphe was in the midline. None of the patient had residual chordee, penile torsion, or glans dehiscence. Excellent cosmetic results were observed in all cases. The complication rate in our series was 8% (two cases). Two patients developed fistula. De-epithelialized flap is a simple method to provide additional covering to the constructed neourethra after Snodgrass urethroplasty. It achieves our goal of noncrossing suture lines and providing maximum vascularity.

HYPOSPADIAS REPAIR

Place of Study: The Departments of Urology, Paediatric Surgery and Plastic Surgery, Quaid-e-AzamMedical College, Bahawal Victoria Hospital, Bahawalpur. Duration of Study: Jan 1999 to Dec 2004. Design of Study:Prospective. Materials&amp;Methods: Patients admitted with hypospadias in these departments were included in this studyexcept patients with multiple failed repairs previously. Standard procedures were practiced for every type of defect i.e.MAGPI and Mathieu’s repair for coronal hypospadias, Snodgrass urethroplasty for proximal and distal penilehypospadias. Results: The age range observed during this study was 1.5 to 25 years while 64% of patients were lessthan 10 years of age. The type of defect was coronal in 25%, penile in 60%, penoscrotal and perineal in 15% of thepatients. Initial success rate was 78% and overall success rate was 92%. Complications observed were fistulaformation 7% , stenosis of anastomotic site 7% and dehiscence of repair 3%. Conclusion: Thorough evaluation ofurethral and penile malformation brings best outcome of surgery for hypospadias. Hypospadias repair should be offeredto the child before school going age so as to prevent psychological impacts of genital malformations.

Lessons learned using Snodgrass hypospadias repair

This is a review of our experience with the Snodgrass technique for distal hypospadias repair and we point to lessons learned in improving results. We reviewed all patients who underwent Snodgrass hypospadias repair for distal hypospadias over a four-year period by a single surgeon. Chart review followed by parental telephone interview was used to determine voiding function, cosmesis and complication rate. Thirty children and three adults were identified. Age at surgery ranged from seven months to 39 years. The urinary stream was straight in 94%, and 97% reported a good or satisfactory final cosmetic outcome. One patient (3.3%) developed a urethral fistula and 21% developed meatal stenosis which required general anaesthetic. The Snodgrass urethroplasty provides satisfactory cosmetic and functional results. High rates of meatal stenosis initially encountered have improved with modifications to technique which include modified meatoplasty and routine meatal dilatation by the parents.

Postoperative nursing experience of SNODGRASS urethroplasty

尿道下裂是小儿泌尿系统常见的先天畸形,发病率为8/1000,目前治疗尿道下裂的方法有很多种,但均因术后并发症多而效果不满意,2000年以来,我院采用Snodgrass尿道成形术治疗先天性尿道下裂患儿50例,获得良好效果,现将术后护理报告如下。

Snodgrass procedure for primary hypospadias repair.

In this study, the authors' experience in adaptation of the Snodgrass technique for primary hypospadias repair, with an alternative way to create a barrier layer of dartos flap for neourethral covering, is presented. Between March 2000 and January 2001, Snodgrass urethroplasty was consecutively done on 24 boys aged between 14 months and 9 years (median: 3 years). The position of the meatus was coronal in one boy, at the distal shaft in two, at mid-shaft in eight, at the proximal shaft in five, penoscrotal in four, scrotal in three and perineal in one. Dorsal plication was carried out in nine patients (37.5%) to correct residual ventral curvature after penile degloving. Postoperatively the neourethra was stented for 10-12 days and suprapubic diversion was used for 12-14 days. Postoperative follow up ranged from 4 to 14 months (median: 8 months). All patients undergoing Snodgrass repair obtained a neourethra with a slit-like meatus at the tip of the glans. A small urethrocutaneous fistula occurred in one patient with mid-shaft and two with proximal-shaft hypospadias (an overall fistula rate of 12.5%). Urethral stricture had not been encountered at the time of this report. One patient developed mild meatal stenosis and was successfully managed by simple dilatation. The results indicate that Snodgrass urethroplasty provides satisfactory cosmetic and functional results and is versatile in repairing almost all types of hypospadias.